Last month I wrote an article that spoke somewhat favorably of the new weight loss drug, Saxenda. I said it was perhaps the most important weight loss medication ever developed.

Wow! Did I get lambasted! I got all sorts of email blasting me for going over to the dark side and becoming a drug pusher and lackey of Big Pharma. I even got an email from my favorite professor of counseling at the University of Massachusetts, now friend, Allen Ivey, Ph.D. Besides being a friend, he is a big shot in the counseling field, the father of Microcounseling and developer of “active listening”. He said he was “sad” to see that I seemed to be pushing drugs. He is the last person on earth that I would want to be mistaken about my views on the solution to obesity. We’ve since gotten that misunderstanding corrected, but I want to make sure it is clear with everyone who reads my blogs.

I am still the world’s staunchest advocate of the behavioral therapy I teach to reverse the condition of obesity. It works -like a miracle, some say. But not 100% of the time. For some, it is not enough.

After 30 years successfully helping people to lose weight permanently, I am convinced that a percentage of the population is dealing with a physiological condition that creates more persistent and intense degrees of craving and compulsion than the rest of us have to deal with. My approach teaches people how to overcome the habits and feelings that make them overweight but sometimes those cravings and compulsions are so strong that nothing on God’s natural earth will quiet them.

If you’ve ever had a blister on your foot or a pebble in your shoe, you’ll remember that your brain is getting the message loud and clear that you need to relieve that pressure and you need to relieve it right now. You will feel the drive to relieve it until you do. It won’t go away until you do whatever it takes. There is no “will-powering” it away. Something is going on in the body, physiologically and chemically, that is triggering a response in your brain that will bother you until you satisfy it. It isn’t exactly the same with the food cravings that some have, but it gives you an idea of what some people are dealing with. Hold your breath for as long as you can and see how powerful the urge to breathe becomes. This is the kind of relentless drive that a small percentage of the population is fighting in their attempts to stop eating too much.

For them, some sort of intervention or tool that would make it easier for them to eat less would be a Godsend. Then, perhaps what they learn in a good behavioral approach would be enough. Self-programming and cognitive techniques like I teach work like magic for many people, but they would be so much more productive for these folks with eating hyperdrive if we could reduce that drive, which the pharmaceuticals can do. Or in the case of surgery, an additional tool to use behaviorally.

Make no mistake about it, drugs or surgery will not by themselves solve your weight problem. To solve your weight problem, you need to make a permanent change in your behavior, made possible with behavioral therapy, taught in my bookand by my therapists. Success comes with learning how to eat what you like in ways that keep you at your desired weight and it becoming habitual and a new “normal” for you. Now, with these new medical interventions, success may be possible even for those who have suffered from an abnormally intensive eating drive. Weight loss drugs or surgery may now enable them to overcome the obstacles that prevented them from being able to make those behavioral changes.

When I was twelve, after countless days of torment over my weight and inability to control it, I would have given anything to have the surgery that would solve the problem for me. I’m glad it didn’t happen. I went on to discover how to lose weight permanently while enjoying eating more than ever, lost over 100 pounds after years of dieting failure, and went on to teach others how, and to write the book about it, The AndersonMethod.

Some think of me as the weight loss counselor’s counselor who is against bariatric surgery, so people are surprised to learn that I’ve recommended bariatric surgery to a number of clients.

In fact, I’ve worked hard to convince some people that weight loss surgery was something they needed to be open to and look into. At times, I’ve told them I think it must be done ASAP. And while my weight loss method is a behavioral approach, teaching people how to form the habits and unconscious behavior to achieve permanent weight loss, I work with many people who have had the surgery. That’s because, even with the surgery, you still need to change your eating habits and change them for life. More on that later.

A few years ago, bariatric surgery started becoming a big business with magazine ads and billboards advertising the different competing hospitals’ surgical weight loss programs. Smiling doctors and attractive stories enticed people. Free seminars offered all your answers. Before and after pictures and stories excited anyone who has dreamed of solving their weight problem. It really bothered me because I knew that lots of people would be drawn to this and choose it, thinking it would relieve them of the need to change their eating habits. They thought that the surgery would be easier than counseling in behavioral therapy, a way to solve the problem for many without the surgery, not to mention being a small fraction of the cost. Many would ignore the risks and downsides of the surgery. They would choose not to consider that they would need to learn how to change their habits anyway and that many people who lost weight with the surgery had not kept it off. I know that weight loss surgery is not the right thing for most of these overweight people.

So, if I’m so sure it’s the wrong thing in many cases, what makes me think it’s the right thing sometimes? The main factor that leads me to advise people to have the surgery is emergency.

Sometimes, the threat from their obesity is so dangerous that life is at stake and there is no certain way to restore hope and eliminate the risk other than the surgery. Simply said, we’ve run out of time. There is no more time to depend on methods that are not absolutely guaranteed to produce immediate dramatic weight loss to prevent further deterioration we may not recover from.

The cases where I’ve prescribed surgery all involve clients who have made sincere heroic efforts, but have been unable to overcome the forces that prevent them from losing weight. They have all reached the point where they have given up hope that they will ever be able to lose weight. Now, let me be clear, it’s normal to become hopeless, even regularly, for people who try to lose weight, but in these high-risk cases, the hopelessness spirals them downward to a deterioration they might not recover from. With most of us, after a while, we are able to see things differently, learn more, and resume the work to get control of the weight and eventually succeed.

What is this deterioration that I say is so dangerous? In some cases, it is mobility. They are just not able to move around without great pain and difficulty, reducing their movement while destroying their spirit. With some, it is a profound hopelessness where nothing but misery and an early death is imaginable, driving them further down a black hole that is dangerous in itself. Some are so medically compromised with dangerous heart conditions and diabetes that they are a ticking time bomb and time is running out. Nothing has worked and they are getting worse.

In all these cases, as soon as the decision to go ahead with the surgery is made, hope is restored. They are able to believe, without doubt, that they will be able to lose weight, because it is the new physical condition, the alteration of their gut, that will cause them to lose weight. They don’t have to depend solely on their own efforts.

Another characteristic that may be present in those I’ll recommend for bariatric surgery is an unusually powerful eating drive that I am certain is biologically based. It is a drive so strong, like that associated with the worst addictive drugs, that we are unable to overcome it, even with the best behavioral interventions we employ. With most people, we are able to answer the cravings in a way that overpowers them, and also employ methods that will reduce or eliminate them. In these worst-case scenarios, the people are unrelentingly tormented by these drives that cannot be overcome. The surgery acts as an additional tool in their toolbox that strengthens their ability to manage their eating, physically limits what they can process and absorb, and may have an important impact on the production of hormone, as we know it does related to diabetes, that influences eating drive and behavior.

How has it worked? I’m happy to say that I am hearing “I’m doing great! I have my life back, better than ever” more often than ever, more often than when I only offered behavioral therapy in my weight loss counseling work. My clients who were spiraling down are getting better, having hope. They are able to apply the behavioral techniques with increased effectiveness. Like my other successful clients, they are mobile again, with less pain and discomfort, ridding themselves of the diabetes and high blood pressure and the medicines they needed to treat them. They are happier with themselves and their lives.

If you have been chronically overweight and unable to achieve the weight loss you want, rest assured that it can be done. Your habits will have to change for life, but that does not have to be by sheer force of will alone. There is a whole body of behavioral technique that I teach, that can be learned, that makes behavior change possible.

But, if you have done all that, learned all you can from me and tried your best, and things are getting worse and you are running out of time, weight loss surgery might be right for you. So says the weight loss counselor’s counselor who people think is totally against bariatric surgery.

William Anderson is a Licensed Mental Health Counselor who specializes in weight loss, eating disorders and addictions. He is the creator of “Therapeutic Psychogenics”, which helped him lose 140 pounds permanently thirty years ago after years of obesity and dieting failure. He has written a book about it, The Anderson Method, and he is teaching these techniques to individuals and therapists all over the country.